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Virtual Medicine services (commonly referred to as “telemedicine” or “telehealth” services) involve the use of secure interactive videoconferencing equipment and/or messaging devices that enable healthcare providers to deliver healthcare services to patients when located at different sites.


The purpose of this form is to inform me of the risks and benefits of a virtual medicine consultation, and to give my consent to participate in such a consultation. Accordingly, I expressly acknowledge the below: 

  1. I voluntarily request and authorize the physician(s), physician assistant(s), nurse practitioners and other healthcare providers of [QuickVisit Urgent Care][1] to conduct a virtual consultation (sometimes referred to as a “virtual visit”) and perform a reasonable and necessary examination of the presenting complaint and recommend treatment.

  2. I understand that the same standard of care applies to a virtual visit as applies to an in-person visit.  

  3. I understand that I will not be physically in the same room as my healthcare provider.  

  4. I understand that a virtual visit is not a substitute for emergency care, and that if I believe emergency care is necessary I will seek out a local provider or emergency department.

  5. I understand that the provision of healthcare, including through a virtual consultation, is not an exact science and acknowledge that no guarantees have been made to me regarding the likelihood of success or outcomes of any virtual visit. Notwithstanding the foregoing, I understand and agree that I will provide the providers with accurate and complete information about my health history and presenting complaint, or those of the patient on whose behalf I am seeking treatment. 

  6. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my healthcare provider or I may discontinue the virtual visit and make other arrangements to continue the visit or obtain care. Additional risks include, but are not limited to:

    1. insufficiency (e.g., poor resolution of videos or images) or delays in information capable of being transmitted and, therefore, inability to properly or timely treat a condition; and

    2. the provider having incomplete access to my complete medical history, which could result in adverse drug reactions or interactions or other judgment errors. 

  7. I understand that the benefits of virtual medicine services include, but are not limited to, easier and quicker access to providers, even at a distance. 

  8. I understand that I have the right to refuse to participate or decide to stop participating in a virtual visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment. I may revoke my right at any time by contacting QuickVisit Urgent Care at [PHONE NUMBER].

  9. I understand that the healthcare provider conducting the virtual visit will inform me about findings discovered during the consultation and may suggest follow-up care with my regular or other qualified provider, but will not monitor my health condition on a continuous basis or provide follow-up care without my specifically requesting it. It is up to me to seek appropriate follow-up care.

  10. I understand that I have the right to be informed about the recommended treatment following a consultation and the risks and hazards involved in connection with such treatment. I also understand that I have the right and the responsibility to participate in the treatment, including by asking questions if I do not understand something. 

  11. I understand that the laws that protect privacy and the confidentiality of healthcare information apply to virtual medicine services.

  12. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. For example my insurance carrier will have access to my medical records for quality review/audit. I understand further that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my virtual visit, and that health plan payment policies for virtual visits may be different from those for in-person visits. 

  13. I understand and acknowledge that I am aware of the alternatives to virtual medicine services and consent to proceed with a virtual consultation.

  14. I understand that this consent will be continuing in nature, including after the conclusion of a virtual visit and after a diagnosis has been made and treatment recommended. 

  15. I understand that this document will become a part of my medical record.   


By notifying on the Clockwise registration page, I hereby fully and voluntarily consent, for myself or on behalf of the patient on whose behalf I am seeking treatment, as applicable, to participation in a virtual visit, and attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had the opportunity to ask questions, and have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to virtual medicine visits shared with me in a language I understand; and (3) am located in the State of Texas and will remain in the State of Texas for the duration of my virtual visit.

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